Everything is being rated these days. But who is rating the ratings? As a public service, I have been blogging about the shortcomings of various rating systems since 2010. Two recent papers on this topic are worthy of review.

In a randomized controlled study, investigators from the University Hospital of Münster, Germany found that medical students who were provided cookies during academic course sessions rated the experience significantly higher than students who did not receive cookies....

<Meanwhile> A research letter from the Cleveland Clinic published in JAMA Internal Medicine looked at over 8,400 patient encounters for respiratory tract infections involving 85 telemedicine doctors and found 66% resulted in an antibiotic being prescribed. The estimated prevalence of bacterial acute respiratory tract infections in outpatients is low. A substantial number of the antibiotics prescribed by telemedicine physicians were probably unnecessary. Physicians received 5-star ratings from 91% of patients who were prescribed antibiotics and 86% of those who received a non-antibiotic drug prescription. When no drugs were prescribed, 72% of patients gave 5-star ratings, a significant difference.

A male physician - one who sits on multiple committees at a large hospital in Dallas - was recently quoted in the Dallas Medical Journal, that female physicians earn less, and they "choose to or they simply don't want to be rushed." Adding, "most of the time, their priority is something else ... family, social, whatever." I should be astounded that a colleague, in 2018, who appears to be about my age, would think so concretely, let alone state it publicly as though he's commenting on a breed of dogs ( "... the female Yorkies tend to shy away from true terrier traits, they are not as hard-working").

I come by many things in my life naturally - my stubbornness, my red hair and my career. I am very fortunate. Unlike many, I am the daughter of a female emergency physician. This is something I never really considered while growing up. Yes, my mom was a doctor. Did she save lives? I guess so. She didn't spend much time talking about life outside of the home and she was still present for many holidays, birthdays, etc. All I knew was that someday I too would be a doctor. When I refused to set foot in the ED (where she worked and I had visited many times), she simply brought the supplies home to repair my lacerated chin. When I had a fever and abdominal pain, I recall the look in her eyes when she recognized my appendicitis. But, that was life in our home. She did not bat an eye when we injured ourselves because she'd seen worse.

After attending an all-female high school, she went on to join the first class at Loyola College of Maryland (now Loyola University) to allow women, attended University of Maryland for medical school and ultimately became board certified in Emergency Medicine (which was not an available residency when she trained).

Promising health studies often don't pan out in reality. The reasons are many. Research participants are usually different from general patients; their treatment doesn't match real-world practice; researchers can devote resources not available in most physician offices. Moreover, most studies, even the gold standard of randomized controlled trials, focus squarely on causality. They are set up to see if a treatment will work in optimal conditions, what scientists call efficacy. They're "explanatory."

In a matter of less than a decade, "shared decision-making" (SDM) has emerged as the uncontested principle that must inform doctor-patient relationships everywhere. Consistently lauded by ethicists and medical academics alike, it has attracted the attention of the government which is now threatening to penalize doctors and patients who do not participate in SDM prior to providing certain treatments, even if the legal process of informed consent has been fulfilled - and even if the treatment is widely considered to be clinically justified.

For example, in a recent issue of JAMA, an editorial approvingly reports that the Center for Medicare and Medicaid Services will soon refuse to pay physicians and hospitals for the implantation of cardioverter-defibrillators unless the decision to implant these life-saving devices was "shared" with the patient. Although the announcement is short on details regarding the formal process by which SDM must be documented to have occurred, the new policy certainly testifies to the unquestioned status SDM has rapidly acquired as a general principle of medical ethics.

"Sorry, I'm running late ... sorry, to keep you waiting." How many times a day do I say that? Sometimes it is every time I walk into a patient's room as if it is a normal greeting. Sometimes patients respond with: "Oh, you aren't late" or "I haven't been waiting long." I can be so obsessed with not being late that I don't realize I'm actually running on time! But I know it is a common complaint that patients "always" have to wait to be seen by their doctor. One of my senior partners at work used to say "waiting for a good doctor is like waiting to be seated at a good restaurant, it is worth the wait," and never worried about time. I admired how thorough he was with his patients - I don't think any of his patients felt rushed or not heard and came to expect waiting for his care.

Come join me for a day and see for yourself why medicine rarely runs on time...

Envision a large, loafy muffin top. Not just a central bulge or even love handles. I'm speaking of an apron of skin and fat that hangs down over many an American's lower torso and groin. Surely you've seen it - you may even have one. Its medical name is the pannus. I had never heard of a pannus in medical school and I still never hear it mentioned outside of the pathology laboratory. In fact, this article is inspired by conversations I've had with friends who know about medicine and who were nevertheless shocked to hear about the pannus.